Insured Nomads - Group Travel Quote Request

Group Travel Quote Request

Broker/Partner Details

First Name*

Last Name*

Title

Primary Email*

Primary Phone

Company Name

Are you representing a Company? Complete this field with your Company Name. Or, if you are doing business as an Individual, then leave this field blank.

Website

Address Line 1*

Address Line 2

City*

State / Province*

ZIP / Postal Code*

Country*

Traveler(s) Details

What is the total number of insureds (add all employees, dependents, guests, etc.)?

What passport(s) country will the travelers be using?

What is the initial or primary country destination?

Would you like the plan to include or exclude travel to the United States?

Exclude US

Include US

Will any traveler be traveling to Belarus, Burma, Cote D'Ivoire, Cuba, the Democratic Republic of Congo, Russia, Iran, Iraq, Liberia, North Korea, Sudan, Syria, Ukraine, or Zimbabwe.*

Plan Details

Which travel product(s) would you like to receive a proposal for this group?

Please enter the earliest start date of your traveler(s).*

Policy end date:

Please select your deductible (in USD):

Please select your Maximum Medical Benefit (in USD):

Would you like to include any additional benefits?

Please Note: For the Multi plans the deductible is set at $250 and the medical maximum benefit is set at $1 million.

How many maximum days per trip would you like?

All travelers must have health insurance in their own country. Do all travelers have health insurance in their home country?*

Yes

Would you like to quote with the Adventure Sports additional benefit?

Yes

Guardian Plans are currently only available for US citizens and residents.

Are all travelers US residents or citizens?*

Yes

Which Guardian Plan would you like quoted?

What deductible would you like quoted (in USD)?

What state or states are travelers residents of? Please list it here or include it in the census.

What is the trip cost for each traveler (or include separately in the census)?

Would you like to quote any additional benefits?

Please upload any supporting documents here: